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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880902
Report Date: 07/26/2022
Date Signed: 07/26/2022 12:52:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220725131214
FACILITY NAME:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR:NEWCOMB, DOLLYFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: 38DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Griselda T. Garcia - AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not follow Covid-19 safety protocols.

Facility did not ensure the facility was free from pests.
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with Administrator Griselda T. Garcia. Below is a summary of the findings of the investigation:

Regarding allegation "Staff did not follow Covid-19 safety protocols": LPA Colvin conducted interviews with staff and resident(s) regarding the allegation. According to interviews conducted, resident (R1) was admitted to the facility on 6/21/22 without a prior negative COVID-19 test. According to statements made by the Administrator, R1 was given a rapid COVID-19 test at the facility the evening after R1 was admitted (6/22/22), though the facility does not have any records of the test. One week after R1 was admitted to the facility, the facility had an outbreak of COVID-19 and all residents were tested for COVID-19, including R1. Since the facility did not obtain a negative COVID-19 test from R1 prior to R1's admission to the facility, which would protect the other residents and staff from posssible exposure to COVID-19, and the facility has no records to provide any test was administered to R1 prior to 6/28/22 when R1 tested positive for COVID-19, the allegation
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20220725131214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
VISIT DATE: 07/26/2022
NARRATIVE
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"Staff did not follow Covid-19 safety protocols" is SUBSTANTIATED.

Regarding allegation "Facility did not ensure the facility was free from pests": LPA Colvin reviewed facility records and documents related to staff shift notes. LPA Colvin observed that on 7/11/22 staff observed that resident (R2) had spilled a soda in their room which lead to ants infesting R2's room. LPA Colvin observed a subsequent staff note from 7/20/22 which again noted ants in R2's bedroom. The subsequent observation of ants in R2's bedroom was over one week since the incident in which R2 spilled soda and staff first acknowledged the presence of ants. Due to the continued presence of ants on R2's room which was verified through record review, the allegation "Facility did not ensure the facility was free from pests" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Administrator Griselda T. Garcia during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20220725131214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2022
Section Cited
CCR
87464(f)(1)
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Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Licensee agrees to implement a recording process for all COVID-19 tests conducted by facility staff and maintain records in resident files. Licensee additionally agrees to submit Statement of Understanding regarding receiving a negative COVID-19 test for new residents. Plan for recordkeeping of all COVID
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Based on interviews conducted, the Licensee did not comply with the above regulation with at least on resident. LPA Colvin confirmed that R1 did not obtain a negative COVID-19 test prior to R1's admission on 6/21/22. This was an immediate health risk to all residents, as there was a subsequent COVID-19 outbreak.
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tests conducted at facility and Statement of Understanding to be submited to LPA Colvin by Plan of Correction date of 7/27/22.
Type B
08/09/2022
Section Cited
CCR
87468,1(a)(2)
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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met by:
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Licensee agrees to thuroughly inspection R2's room to ensure that the insect infestation has been corrected. Licensee additionally agrees to take further pest control measures in the future. Licensee may self-certify once inspection is complete. Self-certification due by Plan of Correction date of 8/9/22.
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Based on record review, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed in staff notes that on both 7/11/22 and 7/20/22 ants were observed to be infesting R2's bedroom. This was a potential personal rights violation of R2.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4